Prior Authorization Request Form: Medications Please type or print neatly. Incomplete and illegible forms will delay processing. II. Member Information I. Provider Information Prescriber name NPI # Member name Today’s date Prescriber specialty Phone Member plan ID # Date of birth Drug allergies Prescriber address Office contact name Fax Pharmacy name Pharmacy phone Plan name and fax for form submission Use the drop down to select the appropriate health plan. III. Drug Information (one drug per request form) Drug name Drug strength Dosage form Dosage interval Quantity per day Diagnosis relevant to this request ICD-9 code Expected length of therapy Number of refills IV. Drug History for this Diagnosis A. Is the prescription for a drug to be administered in the office or for the member to take at home? B. Is the member currently treated on this drug? Yes: how long? C. Is this request for continuation of a previous approval? [go to item C] Yes [go to item D] office home No [skip items C and D; go to item E] No [skip item D; go to item E] D. Has strength, dosage or quantity required per day increased or decreased? Yes [go to item E] No [skip item E; indicate rationale in Section V and submit form] E. Please indicate previous treatments and outcomes with other medications below. Drug name Strength Directions Dates of therapy Reason for failure or discontinuation V. Rationale for Request and Pertinent Clinical Information (attach additional sheets if more space is needed) Appropriate clinical information to support the request on the basis of medical necessity must be submitted. Prescriber/Authorized Representative signature Date Plan Fax Numbers Rev. 04192013 Absolute Total Care . . . . . . . . . . . . . . 1.866.399.0929 Advicare. . . . . . . . . . . . . . . . . . . . . 1.866.255.7569 BlueChoice HealthPlan Medicaid . . . 1.866.807.6241 FFS Medicaid. . . . . . . . . . . . . . . . . . . . 1.888.603.7696 First Choice by Select Health. . . . . . . . . 1.866.610.2775 Molina Healthcare of SC. . . . . . . . . . . 1.855.571.3011 Wellness of SC. . . . . . . . . . . . . . . . . . . . 1.866.354.8709